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CLINICAL REVIEW: Timothy J Wilt and James N’Dow Benign prostatic hyperplasia. Part 1—Diagnosis BMJ 2008; 336: 146-149 [Full text]

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if you don't put your finger in it...

Jeremy L Menage   (23 January 2008)

"Benign" is superfluous

Deryck A. Taylor   (24 January 2008)

Re: if you don't put your finger in it...

Timothy Wilt   (26 January 2008)

Bladder Outflow Obstruction or Bladder Weakness?

George GMC Wolfs   (30 January 2008)

Misuse of the term BPH

Paul Abrams   (8 February 2008)

if you don't put your finger in it... 23 January 2008
Jeremy L Menage, GP Nuneaton CV10 0PB Send response to journal: Re: if you don't put your finger in it...	I found this article unhelpful from the point of view of a GP seeing a man presenting with lower urinary tract symptoms, who is worried about cancer. I don't see how it would reassure him to know that he is no more likely to have cancer than someone without these symptoms. The point is that he has got symptoms, and wants an explanation. How do I know he hasn't got an invasive carcinoma? Surely digital rectal examination(DRE) and prostate specfic antigen (PSA) have a part to play here. In fact the American Urological Association guidelines, which are cited in the next paragraph, specifically advise DRE and PSA in the routine workup of these patients. The use of PSA in asymptomatic men, as a population screening tool, is a different issue. Competing interests: None declared
"Benign" is superfluous 24 January 2008
Deryck A. Taylor, Consultant Pathologist Cape Town 7925 Send response to journal: Re: "Benign" is superfluous	Am I the only one to regret the hijacking of pathology nomenclature for inappropriate usage? During the now fleeting contact with Pathology that modern medical education deems adequate for students, time constraints may compromise attempts to convey the vital distinction between "hyperplasia" and "neoplasia". Clarity for these students over a fundamental is not helped when prostatic hyperplasia is pleonastically referred to as "benign", as if it were a variety of neoplasm. Competing interests: None declared
Re: if you don't put your finger in it... 26 January 2008
Timothy Wilt, Professor Minneapolis VA Center for Chronic Disease Outcomes Research. Minneapolis MN, USA 55417 Send response to journal: Re: Re: if you don't put your finger in it...	We thank Dr. Menage for his statements highlighting the widely held, but incorrect viewpoint, that men with lower urinary tract symptoms are at higher risk for having prostate cancer than men without symptoms. Therefore, he believes that the decision to perform a PSA test and/or Digital Rectal Examination (DRE) for the purpose of prostate cancer detection should be based on the presence or absence of these symptoms. We referenced a recent high-quality systematic review demonstrating that men with lower urinary tract symptoms (LUTS) are not at any greater risk for prostate cancer than asymptomatic men. In men with LUTS, PSA levels are frequently elevated due to the presence of much more common noncancerous conditions including urinary infection, prostate enlargement or inflammation. The predictive value of the PSA test is worse in men with LUTS than in men without symptoms. Thus, the routine use of PSA tests in men with LUTS leads to increased false positive findings, unnecessary prostate biopsies and serendipitous detection of clinically insignificant tumors. The accuracy of the DRE is poor and very examiner dependent. Some men may request a PSA test and DRE because they fear their symptoms are due to prostate cancer. However, normal test results do not rule out prostate cancer. Reassurance that their symptoms do not put them at at any greater prostate cancer risk than men without symptoms can reduce worry and unnecessary additional diagnostic tests in many of these men. The decision to perform a DRE or PSA blood test for prostate cancer detection should be made only after informing men who express interest in these tests of their known harms and unproven but potential benefits. This recommendation is supported by numerous reviews and evidence based guidelines referenced in our article. Men can be reassured that their individual prostate cancer risk is not increased by the presence of LUTS. They should also be informed that because LUTS can elevate PSA values the chances that additional diagnostic testing, including prostate biopsy, will be increased compared to men without symptoms. If a man prefers testing after weighing this information then the combination of the DRE and PSA blood test with subsequent urological followup for evaluation of abnormal results will result in the greatest likelihood of detecting prostate cancer. Whether such testing improves survival or quality of life is not known and requires completion of ongoing randomized screening and treatment trials. Competing interests: None declared
Bladder Outflow Obstruction or Bladder Weakness? 30 January 2008
George GMC Wolfs, GP and coordinator of GP clerckship, Dep. Gen Pract, Maastricht University Deb1, 6200 MD Maastricht, the Netherlands Send response to journal: Re: Bladder Outflow Obstruction or Bladder Weakness?	Your article puts 3 unanswered diagnostic key questions, and we have population based answers on the last 2. All men above 55 years or older were addressed at 10 GPs. On the basis of symptoms (modified Boyarski) and/or abnormal uroflow, 148 men entered bladder pressure studies. Qmax < 10 ml/s was present in 52%, symptoms in 46%. Postvoid residual volumes > 100 ml were detected in 50%, bladder outflow obstruction (BOO) in 40% (URA > 29 cm water), bladder weakness (BW) in 71% (Wmax <9.9 W/m2). Mean prostate size 25.5 ml, Mean micturition volume 220 ml. Only 21% of men were studied for micturition by a doctor before our study. No relation was observed between BOO and any of the symptoms, but urge incontinence reached p <0.05. BOO was negatively related with urinary peakflow and positively with postvoid residual volume (PVR). In Multiple Logistic Regression analysis PVR > 200 ml, Qmax in quintiles and artefact on flow curve were significant. BW was unrelated to any clinical finding. Conclusions: in the community of elderly men, BOO and especially BW frequently occur using urological definitions of abnormality. A relevant relation between these urodynamic standard diagnoses and symptoms was hardly found. But PVR and Qmax were factors indicating BOO. Our data were -sadly enough- not used for prognostic study. The above mentioned data were published in my thesis: Obstructive micturition problems in elderly male: prevalence and diagnosis in general practice, Maastricht, the Netherlands, 1997 and were not published in any form elsewere. Competing interests: None declared
Misuse of the term BPH 8 February 2008
Paul Abrams, Professor of Urology Bristol Urological Institute, Southmead Hospital. Bristol BS10 5NB Send response to journal: Re: Misuse of the term BPH	Drug companies market drugs for “BPH”. However, this is a misuse of the term, which all dictionaries define as a histological term and not a term related to gross anatomical change. It is, therefore, disappointing that the BMJ has commissioned review articles on “BPH”. A number of important organisations - ICS (1), ICUD Prostatic Consultations (2) and BAUS (3) have accepted the arguments put in a BMJ leader in 1994 (4) that the term LUTS should be used rather than “prostatism” and now “storage” and “voiding” symptoms are the preferred terms to “ “irritative” and “obstructive” symptoms. However, the above organisations also supported the proposal (4) for the proper use of the terms BPH (histology), BPE (enlargement) and BPO (obstruction). It is regrettable that regulatory authorities, journals like the BMJ and drug companies have not recognised the wisdom of using the correct terminology (BPH/ BPE/BPO) which is likely to protect men from inappropriate treatment and help ensure that men get care focused on the cause of their LUTS. The problem is that all men have prostates and if they live long enough will get histological BPH : in more that 50% of men aged 50 and 80% of men aged over 70. However, only a quarter of those with BPH will get BPO. It seems highly unlikely that the gradual development of either BPH or BPE, without obstruction, is likely to cause bothersome LUTS. The article mentions the causes of LUTS other than prostatic obstruction; however, the emphasis is on the prostate and, unless clinicians appreciate the increasing prevalence of overactive bladder and nocturnal polyuria, then men are unlikely to get the help they need when they present to the clinicians with symptoms that affect their quality of life. Reputable institutions, like the BMJ, need to be sure that they reinforce science and not the inappropriate misuse of terms that may prejudice the care of patients. References: 1. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A : Standardisation Sub-committee of the International Continence Society. The standardisation of terminology of lower urinary tract function : report from the Standardisation Sub- committee of the International Continence Society.Neurourol Urodyn 2002; 21 (2) : 167-78 2. Male lower urinary tract dysfunction : evaluation and management. Eds : McConnell J, Abrams P, Denis L, Khoury S, Roehrborn C. Publ : Health Publications 2006 3. Speakman MJ, Kirby RS, Joyce A, Abrams P, Pocock R : The British Association of Urological Surgeons. Guideline for the primary care management of male lower tract symptoms. BJU Int 2004 May; 93 (7) : 9895-90 4. Abrams P. New words for old : lower urinary tract symptoms for “prostatism”. BMJ 1994 Apr 9; 308 (6934) : 929030 Competing interests: Paul Abrams is or has been a consultant, lecturer, investigator and / or the recipient of educational grants from companies marketing products for the treatment of prostatic obstruction, overactive bladder and nocturia.